Epidemiological behavior of suicide attempt in Colombian adolescents years 2016-2019: An ecological study

Abstract Objective: characterize the behavior of attempted suicide in adolescents in Colombia, and its associated epidemiological factors from 2016 to 2019. Method: quantitative, observational, descriptive, and ecological study. The sample was extracted from the database of the Integrated Social Protection Information System, by identifying cases of attempted suicide for ages in the range from 12 to 17 years old, calculated for a prevalence estimate based on a total population of 32,076. Univariate and bivariate analysis of the variables of interest was performed. Results: suicide attempts occurred more frequently in females (n: 24,619; 76.7%), of subsidized regime (n: 17,960; 56%); and being in psychiatric centers is the most frequent vulnerability condition (n: 676; 2.11%). Living in the capital city is a risk factor for attempted suicide (OR: 1.423; 95% CI: 1.385 to 1.462), while being male is a protective factor (OR: 0.290; 95% CI: 0.283 a 0.298). Conclusion: suicide attempts are a subject of interest in Public Health due to their prevalence and impact on the family and social environment. The Nursing professional is competent in the identification, treatment, and prevention of this phenomenon.


Introduction
Suicide is a phenomenon that begins with suicidal ideation and intention until its consummation. In this context, suicide attempt presents a set of behaviors initiated by the subject who, in carrying them out, has at least some intention to die, although these may or may not cause medical injuries (1) . According to the World Health Organization (WHO), there are many suicide attempts for every completed suicide and, in the population at large, an unfinished suicide attempt is the single most important risk factor (2) .
In this perspective, suicide is the fourth leading cause of death among young people aged 15-19 years old, and rates are higher among vulnerable and discriminated groups such as refugees and migrants, indigenous peoples, lesbian, gay, bisexual, transgender and intersex persons (2) . According to data from the Similarly, it is possible to identify risk factors associated with suicidal ideation in adolescents in Colombia, which are related to aspects such as history of bullying, physical or sexual abuse, mental or physical illness, academic losses, unstable love relationships, difficulty tolerating economic problems, and social accommodation, abuse of psychoactive substances and intrafamily dysfunction (4) .
In this sense, it is evident that the problem has not yet been addressed in the historical-retrospective or academic context with a nursing mission approach.
Even when there are research advances at the psychosocial level, these are only used as a reference for the Nursing professional, addressing social, medical, biological and scientific aspects contemplating a holistic approach to the person prone to suicide.
However, the nursing professional plays a very important role in providing humanized and holistic care with a scientific basis (5) , in addition to bearing effective competencies for prevention applied through health education. Therefore, approaching adolescents to inform and reduce the risk factors for suicide attempts would reduce this increasing social problem. Likewise, within the group of healthcare professionals, Nursing maintains direct contact with the patient, since the therapeutic relationships established are usually very close, making easier to learn about the concerns and emotional condition of adolescents (6) .
Likewise, there is significant interest and concern by healthcare professionals, particularly Nursing professionals in addressing, preventing and intervening in suicidal behavior. This is evidence of an absolute consideration of the need for care (7) .   included. Reports with incomplete information in the databases were excluded.

Analysis planning
The analysis consisted of two phases, one univariate and the other bivariate. The univariate phase allowed each variable of interest according to its nature to be reviewed by means of frequency measures (percentages with their relative and absolute frequencies) and central tendencydispersion (for quantitative variables). Moreover, tables and schemes were developed to present data in a more organized way. In addition, population prevalence was calculated using the population projections of the National Administrative Department of Statistics (DANE) as reference.
The bivariate phase allowed the calculation of crude risk estimators of the Odds Ratio (OR) type with significance when obtaining a p less than 0.05, and with their confidence intervals at 95%. In the development of this phase, general population data were compared with the data obtained from the population with suicide attempt in these same age groups. This statistical processing was performed using the free statistical program OpenEpi.

Bias control
The applicable criteria for an observational ecological study from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist were followed for the reporting of this study.
To mitigate selection bias, we considered only reports with a confirmed suicide attempt reported in the SISPRO server, and cases that before being made public undergo a process of validation of the information at the level of the Colombian Health System.

Results
In the debugging of the SISPRO database, out of a total of 32,226 records 150 (0.4%) were discarded as they did not meet the selection criteria, did not have complete information, and had errors in the report.
Univariate and bivariate analysis was performed.  (Figure 1). This event of Public Health concern occurred more frequently in adolescents aged 15 to 17 years (n: 6,797 -21%; n: 6.694 -21% and n: 6,565 -20%, respectively), and the most frequent type of scheme is subsidized (n: 17,960; 56%) (       According to WHO data for 2021, more than 700,000 people in the world die by suicide each year (9) , which is a topic of interest in Public Health due to its high prevalence, the economic burden it generates and the impact it has on the family and social environment (10) .

Discussion
Likewise, it represents the fourth leading cause of death among young people aged 15 to 19 years, which becomes really worrying because of the increasingly earlier age range, since for each suicide recorded, there are many more people who attempted suicide. Therefore, information on a previous suicide attempt becomes relevant, since it is the most important risk factor to foresee a future attempt (10) .
In relation to biological sex, this research reflects a behavior similar to that reported in another study developed in Barcelona, Spain (10) , which shows that women make more suicide attempts than men. In fact, from 2018 to 2019 twice as many episodes were documented by women, with no significant differences during the pandemic. However, there was an increase in consultations for suicidal ideation among the younger population possibly derived from confinement, which resulted in increased irritability, anxiety, depression and psychological distress due to increased exposure to the media and uncertainty about the future (20)(21) .
Regarding as the difficulty to connect with others, feelings of loneliness and isolation that lead to negative thoughts about their lives (23) .
Associated with this situation, people in vulnerable situations or belonging to social minority populations show higher risk of suffering from mental disorders, since due to their minority status they are at a disadvantage in relation to the predominant or majority social sectors (24) .
For example, migrants or people with scarce resources may present greater socioeconomic problems and greater deprivation of basic needs, which leads to thoughts of anguish and hopelessness that may be translated into self-harming actions.
On the other hand, it is important to pay attention to the group of pregnant women, since a study found that the prevalence of psychopathological antecedents, sadness, adjustment disorder with anxiety and depressed mood were risk factors that influenced a subsequent suicide attempt (25) .
In this regard, literature shows that it is prudent for different health professionals and the community in general to be alert to the possibility of suicidal ideation in adolescents who report feeling more irritable or worried than usual; who manifest negative feelings, such as pessimism, sadness, fear of the future, anxiety that up of these individuals (18) .
Along the same lines, although the approach to adolescents at risk of suicide should be multidisciplinary, nursing professionals and especially mental health specialists play a crucial role in the detection of suicidal behavior and the promotion of healthy lifestyles. These professionals are competent to act with people at risk of suicide, helping them to reflect on the reasons that motivate them to make this decision. There is scientific evidence that some suicides could be prevented with a risk assessment and intervention and care by Nursing professionals (29) .
In this exercise of care by Nursing professionals, group in a rapid, effective and sustainable manner (33) , since there is a worldwide absence of specific mental health policies for children and adolescents, which may delay the care process and the prevention of suicidal behaviors (34) . Likewise, the discipline demands wise actions and decision-making focused on the Sustainable Development Goals (35) .